I, Dr. , hereby apply to be enrolled as a Life Member of The Pakistan Association of Dermatologists. I have read the rules and regulations of the Association and agree to abide by them. My
Curriculum Vitae are as follows:

LAST NAME

FIRST NAME

FATHER'S / HUSBAND'S NAME

ADDRESS

PHONE Residence

PHONE Clinic

PHONE Hospital

E-mail

MOBILE

DATE OF BIRTH

QUALIFICATIONS

PMDC Reg No.

APPLICANT'S SIGNATURE

PROPOSED BY

SIGNATURE

SECONDED BY

SIGNATURE

Dr. Doctor Khan WazirGENERAL SECRETARY
(2019)

Dr. Javed Ahmed MemonTREASURER
(2019)

Encl:

Photocopies of Degrees, Diplomas and Valid P.M.D.C. certificates

A Valid PMDC Certificate is required with Endorsed Postgraduate Qualifications.

2 P.P SIZE Photographs (INCOMPLETE FORMS SHALL NOT BE ACCEPTED)

PAKISTAN ASSOCIATION OF DERMATOLOGISTS
DATA FORM LIFE MEMBER'S DIRECTORY